Work flow analysis critical after EHR purchase

An accurate mapping of the process patients encounter through clinical visits and care episodes helps practices identify waste and areas that need improvement.

By — Posted April 29, 2013.

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A lot of assumptions are made about how an electronic health record system will help a practice achieve certain outcomes or reach particular goals. But the only way to determine whether those assumptions were correct is to perform a work flow analysis.

It's a process most practices complete before an implementation. Experts say the best way to choose an EHR is to perform a work flow analysis, then find an EHR that matches the desired work flow. Practices should view the post-purchase work flow analysis as a checkup for their practice. The more thorough the analysis, the clearer picture a practice will have of what's working, what's not, or what needs tweaking before it turns into a problem.

Even if the practice believes it has achieved excellence in a certain area, “you know that you need to sustain it,” said Sam Cykert, MD, clinical director of the North Carolina Healthcare Information and Communications Alliance, which runs the state's regional extension center.

Practices always should look for ways to improve, said John Gallagher, account manager for Simpler Consulting, a health care consulting firm. The firm works with physician practices to employ the Toyota “lean management” technique, which focuses on eliminating waste and increasing efficiencies. “You're never perfect,” he said. But each work flow analysis will help practices make improvements that move them closer to perfection.

The work flow analysis maps each process associated with a patient's journey through a practice, looking at the input and output of information associated with each step, Gallagher said. It should start with the patient checking in and include all the “touches” the patient experiences throughout the visit until he or she has a care plan in hand and is ready to walk out the door.

But it doesn't end with the patient leaving the practice. The analysis should include the mapping of what happens after the visit — how lab results are handled, how follow-up phone calls or emails are managed, and the process for referrals.

Experts recommend that practices conduct work flow analyses frequently in the first year or so after an EHR implementation. Then they should be conducted, at minimum, on an annual basis. But the analysis should not center around how the EHR handles each step of a patient visit and the information flow that accompanies it. Rather, the analysis should look at the human element of how each task is handled and how the EHR acts as a tool in that process, said Nancy Fennell, director of the Regional Extension Center of New Hampshire.

“Who's going to open up the note?” she asked. “Who's going to be the one to record the medications or the allergies? Does the note have to be opened by the provider before the medications can be documented?”

Steps to a good work flow analysis

To help ensure that a practice performs the most effective analysis possible, there are best practices they can follow:

Use a cross-functional team. Because each person in a practice has his or her own roles, a member from each department should be included in the work flow analysis. Gallagher said he recommends including patients so that the practice can see the process through a value stream perspective. Each part of the process must provide some value to the patient, he said.

Map each type of patient visit. Generally, 80% of primary care visits are made up of well visits, sick visits, routine follow-up and chronic disease management, Gallagher said. Each involves a unique work flow with steps that other types of visits would not have. Each needs to be mapped separately.

Approach the analysis from a goal-achieving perspective. Before a practice goes live with its EHR system, it should have established goals, each one with a specific measure of success, Dr. Cykert said. For example, a practice may want to improve A1c levels for its diabetic patients. If the goal has not been reached, the work flow analysis can help the practice identify where breakdowns might be occurring. If the goal has been reached, an analysis could help the practice determine ways to reach an even higher goal.

Meaningful use is a good place to start when it comes to goal-setting, said Jaime Dupuis, practice consultant with the Regional Extension Center of New Hampshire. The program has several quality reporting measures that involve collecting data that practices were unable to track before EHRs. A work flow analysis will help ensure that data are being collected and that the person collecting each set of data is the most appropriate person for that task.

Check data flow. An important piece of the work flow analysis is ensuring that data are being moved to the right people at the right time during the process. Therefore, practices need to confirm that this transfer of information has taken place. Fennell said a practice she worked with had a very efficient paper process for dealing with lab tests. When the process was moved to the EHR, no one realized that the machine, once well-oiled, had some hiccups and that some data were not making their way into the patient record. No one knew, because there was not a reconciliation process.

Because of meaningful use, Dupuis said, some practices might be tracking data they never tracked before. For example, she said an ob-gyn practice was not recording patients' entire problem lists in their records, as required under meaningful use. They were used to charting only problems specific to an ob-gyn visit. The meaningful use regulations can serve as a good reconciliation tool to make sure practices are capturing the required data for that program.

During the work flow analysis, practices should remember that the EHR is a tool. “That's all it is,” Dr. Cykert said. “It's the people who have rules in using the tool that make good. EHRs do improve care a bit, but it's engaging different members of the office staff in that process that really makes a difference.”

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